RESUMEN

The acutely swollen knee is a common presentation of knee pathology in the emergency department and the primary care setting, whether on board ship, in a Regimental Aid Post, or in a Medical Centre. The swollen knee has both traumatic and atraumatic (systemic) causes, all of which can be accurately diagnosed with an understanding of the underlying injury patterns and patho-anatomy. In Part 2 of this paper we consider the traumatic causes and also suggest a combined approach to managing an acutely swollen knee. The taking of a detailed history combined with thorough clinical examination will establish the diagnosis or at least the narrow differential diagnosis in the majority of cases. The use of specialist examination techniques, diagnostic imaging and arthrocentesis can further assist the clinician in confirming the correct diagnosis and thus prescribing the appropriate treatment. This review will endeavour to give a consensus of opinion and structured guidelines in the diagnosis and initial management of patients presenting with acute or recent onset swelling of the knee.

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RESUMEN

The acutely swollen knee is a common presentation of knee pathology in the Emergency Department and the primary care setting whether on board ship, a Regimental Aid Post or Medical Centre. The swollen knee has both traumatic and atraumatic (systemic) causes, all of which can be accurately diagnosed with an understanding of the underlying injury patterns and patho-anatomy. In Part One, we will be examining the management of non-traumatic causes, followed by Part Two, looking at traumatic causes, in the next issue of the Journal. A detailed clinical history combined with thorough clinical examination will establish the diagnosis, or at least the narrow differential diagnosis in the majority of cases. The uses of specialist examination techniques, diagnostic imaging and arthrocentesis can further assist the clinician in confirming the correct diagnosis and thus prescribing the appropriate treatment. This review will endeavour to give a consensus of opinion and structured guidelines in the diagnosis and initial management of patients presenting with acute or recent-onset swelling of the knee related to atraumatic pathology.

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Lower leg pain is a common complaint of athletically active individuals, often limiting physical activities. As such, the group of lower leg conditions related to athletic pursuits and physical exercise confer considerable operational implications for the military. Whilst acute injuries to the lower limb are commonly encountered and are clearly of significance, this article focuses instead on chronic conditions related to physical activity. These include insults to bone such as stress fractures and medial tibial stress syndrome, and those related to the soft tissues such as chronic exertional compartment syndrome. In this article we will examine the presentation and management of these conditions.

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We report ten-year clinical and radiological follow-up data for the Sigma Press Fit Condylar total knee replacement system (Sigma PFC TKR). Between October 1998 and October 1999 a total of 235 consecutive PFC Sigma TKRs were carried out in 203 patients. Patients were seen at a specialist nurse-led clinic seven to ten days before admission and at six and 18 months, three, five and eight to ten years after surgery. Data were recorded prospectively at each clinic visit. Radiographs were obtained at the five- and eight- to ten-year follow-up appointments. Of the 203 patients, 147 (171 knees) were alive at ten years and 12 were lost to follow-up. A total of eight knees (3.4%) were revised, five for infection and three to change the polyethylene insert. The survival at ten years with an endpoint of revision for any reason was 95.9%, and with an endpoint of revision for aseptic failure was 98.7%. The mean American Knee Society Score (AKSS) was 79 (10 to 99) at eight to ten years, compared with 31 (2 to 62) pre-operatively. Of 109 knee with radiographs reviewed, 47 knees had radiolucent lines but none showed evidence of loosening.

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We report the delay in diagnosis of a Neck of Femur (NOF) stress fracture in mixed sex basic military training. Stress fractures are common in military training with the incidence reported as ranging between 3.2-31%. NOF stress fractures, whilst only representing around 8% of stress fractures are associated with a high morbidity. It is imperative that medical officers looking after military recruits have a sound knowledge of the potential signs, symptoms and presentation of these injuries. Medical officers should always remains vigilant for stress fractures especially in mixed military training.

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INTRODUCTION: We have previously shown that Picolax bowel preparation causes a significant dehydrating effect, which can be minimised by administering a calculated volume of intravenous fluid. The aim of this prospective study was to assess whether peri-operative outcome is affected by administering a calculated volume of intravenous fluid during bowel preparation. PATIENTS AND METHODS: Patients having bowel preparation (Picolax: Ferring Pharmaceuticals Ltd, Middlesex, UK) prior to colonic surgery were prospectively randomised to receive no intravenous fluid (group 1) or calculated intravenous crystalloid based on their body weight (group 2), during preparation. In both groups, transfusion was protocol-driven. Outcome variables measured included intra-operative and postoperative intravenous fluid requirement, hourly recorded urine output for 24 h, number of patients transfused, number of units of blood transfused, time to the passage of flatus, time to having their bowels open, time until tolerating a full diet, complications and length of stay in hospital. RESULTS: Thirty-three patients were recruited - group 1 (n = 18) and group 2 (n = 15). There were 24 men and 9 women, median age 69 years (range, 29-86 years). There was no significant difference between the groups with respect to age, sex, weight, ASA grade, pre-operative haemoglobin concentration, duration or type of operation. The total number of patients receiving a transfusion (P = 0.026) and the number of units of blood transfused (P = 0.017) was significantly greater in group 1. The number of units of blood transfused intra-operatively was significantly greater in group 1 (P = 0.029). Significantly fewer patients had a urine output < 30 ml/h in the first 24-h after operation (P = 0.046) in group 2. There was no difference between groups in other outcomes measures. CONCLUSIONS: This study indicates that a calculated volume of intravenous fluid administered during bowel preparation improves patient outcomes with respect to blood transfusion and postoperative oliguria. We advocate calculated intravenous fluid administration in all patients undergoing bowel preparation prior to colonic surgery.

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